The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

MEMORIAL HOSPITAL 4500 MEMORIAL DRIVE BELLEVILLE, IL 62226 Nov. 16, 2011
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
A. Based on review of medical records, review of Hospital Bylaws, Rules and Regulations, Hospital Policies and Procedures, the Emergency Department (ED) central log, Hospital transfer form, ED physician roster, ED physician schedule, Emergency Medical Services(EMS) summary report, and staff interview, it was determined the the Hospital failed to document all patients on a central log when presenting to the Hospital ED, refer to A2405. The Hospital failed to provide an appropriate Medical Screening Examination (MSE) to all patients that presented to the ED, refer to A2406. The Hospital failed to ensure an appropriate transfer process was followed, refer to A2409.
VIOLATION: EMERGENCY ROOM LOG Tag No: A2405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

A. Based on a review of hospital policy and procedure, Emergency Medical Services (EMS) summary report, a review of the central log, and staff interview, it was determined that in 1 of 5 (Pt #1), Emergency Department (ED) records reviewed which involved the transfer of the patient, the Hospital failed to ensure all patients that presented on the central log.

Findings include:

1. The Hospital's policy and procedure titled, "EMERGENCY MEDICAL TREATMENT AND ACTIVE LABOR ACT" (Policy No: AP 194) effective 2/2010 was reviewed on 11/15/11. It indicated under "V. PROCEDURES: 8. Records and Records Retention - A centralized log of patients presenting to the Emergency Department, or Labor and Deliver shall be maintained and include: A. Date, time and mode of arrival, B. Age, sex and name of patient..."

2. The EMS summary report of Pt. #1, was reviewed on 11/15/11. It indicated on 10/23/11 "Dispatched to an emergency call for a [AGE] years old male patient suicidal. Upon arrival Pt. #1 found sitting on the curb at a gas station. Police Chief was on scene. PD (Police Department) said that pt #1 was suicidal and that Police Chief was calling around for a bed...The Police Chief told Emergency Medical Technicians (EMTs) that the hospital had a psych bed available. EMTs began to transport to hospital ... hospital was contacted by cell phone when EMTs were 5 min away. Hospital ER (emergency room ) told EMTs that the hospital was not a psych facility. EMT told the hospital that PD called and that the hospital said the hospital had a room available and that the hospital was the closest Hospital. Hospital said to continue transport. When EMTs arrived at the hospital a nurse came out to meet EMTs. The nurse said that EMS were supposed to go to receiving hospital. EMT went into ER with nurse to confirm that EMS were supposed to go to receiving hospital. Another nurse told EMTs that EMS are supposed to go to receiving hospital and that the receiving hospital were expecting EMS. EMT was also told that receiving hospital had received the call from PD. EMT got back into the ambulance and told the pt. #1 that EMS are going to receiving hospital instead. Pt. #1 said okay and went back to resting..."

3. The Hospital's computerized central log was reviewed for the month of October 2011. There was no documentation in the central log that indicated Pt #1 had presented on October 23, 2011.

4. During an interview with the Emergency Services Director and the Nursing Director of the Emergency Department, conducted on 11/15/11 at 3:30 PM, the above finding was confirmed.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

A. Based on a review of policy and procedure, EMS call report, EMS summary report, review of ED central log, internal documentation, review of medical record from receiving hospital, and staff interview, it was determined that in 1 of 5 (Pt #1), ED records reviewed, the Hospital failed to ensure all patients that presented to the ED were provided with a Medical Screening Examination (MSE).

Findings include:

1. The Hospital policy and procedure titled, "EMERGENCY MEDICAL TREATMENT AND ACTIVE LABOR ACT" (Policy No.: (AP 194) effective 2/2010 was reviewed on 11/15/11. It indicated under, "II. POLICY: All patients seeking emergency care shall receive an appropriate Medical Screening Examination and evaluation ("screening") to determine whether an Emergency Medical Condition (EMC) exists..."

2. The EMS call report of Pt. #1 was reviewed on 11/15/11. It indicated " The ambulance crew contacted the hospital. Transcript of the call follows: "
Unit Secretary (US) - Hospital (MH): Unit calling. Hospital. Go ahead.
Medstar Emergency Medical Technician (MS-EMT): " Yes, this is 4 Charles 103. I am bringing you a [AGE] year old male complaining of suicidal thoughts. He has a history of depression. He is on Cymbalta and Prednisone. He has a Blood Pressure of 130 over 82, Pulse is 59 O Sat 92%, Respiration 16 ... ...
ECRN-MH: " 4 Charles 103 ...uh ...are we your closest facility for the appropriate treatment for this patient? "
Emergency Communication Registered Nurse - Hospital (ECRN-MH): " Okay. Uh. First of all I have to clear that we are not a hospital that admits psych patients here. And in this instance what is appropriate is for him to go to the closest appropriate hospital. "
MS-EMT: " Then you are the closest facility out of all the hospitals. "
ECRN-MH: " Okay that ' s clear. We will see you when you get here. "

3. The EMS summary report of Pt. #1, was reviewed on 11/15/11. It indicated on 10/23/11 "Dispatched to an emergency call for a [AGE] years old male patient suicidal. Upon arrival Pt. #1 found sitting on the curb at a gas station. Police Chief was on scene. PD (Police Department) said that pt #1 was suicidal and that Police Chief was calling around for a bed...The Police Chief told EMTs that the hospital had a psych bed available. EMTs began to transport to the hospital ... hospital was contacted by cell phone when EMTs were 5 min away. Hospital ER (emergency room ) told EMTs that the hospital was not a psych facility. EMT told the hospital that PD called and that the hospital said the hospital had a room available and that the hospital was the closest Hospital. Hospital said to continue transport. When EMTs arrived at the hospital a nurse came out to meet EMTs. The nurse said that EMS were supposed to go to receiving hospital. EMT went into ER with nurse to confirm that EMS were supposed to go to receiving hospital. Another nurse told EMTs that EMS are supposed to go to receiving hospital and that the receiving hospital were expecting EMS. EMT was also told that receiving hospital had received the call from PD. EMT got back into the ambulance and told the pt. #1 that EMS are going to receiving hospital instead. Pt. #1 said okay and went back to resting..." Pt. #1 was transferred to receiving hospital without having received an MSE.

4. The Hospital's computerized central log was reviewed for the month of October 2011. There was no documentation in the central log that indicated Pt #1 had presented on October 23, 2011.

5. Internal Documentation from the ED Charge Nurse (E#2) dated 10/28/11, was reviewed on 11/15/11. It indicated that the E#2 received a phone call from the ED physician stating that there was a suicidal patient( Pt. #1) coming and E #2 stated the hospital was required to accept Pt #1 and that P. # 1 could not be diverted to a psych facility. E #2 was informed by the ED secretary (E#3) that the E#3 spoke with the receiving hospital and receiving hospital was expecting Pt. #1. The E #2 meet the EMTs in the ambulance bay and informed the EMTs that EMTs were at the wrong facility and the receiving hospital is expecting Pt. #1 and then EMS took Pt. #1 to receiving hospital

6. The medical record of Pt. #1 from receiving hospital was reviewed on 11/16/11. Pt #1 presented to receiving hospital ED per EMS on 10/23/11 at 5:22 AM with the Chief Complaint of " Suicidal Ideation. Nursing documentation indicated the following. Pt #1 had a history of Anxiety and Depression. Physician documentation further indicated a history of Bipolar Disorder. Nursing documentation indicated that Pt #1 broke up with girlfriend today and having problems with sister. Was just going to try and kill self. Girlfriend hit Pt. #1 with a car 10/22/11 at 8:00 PM. Having neck pain now ... " At 5:25 AM, nursing documentation indicated the Nursing Supervisor was notified " that pt. #1 was brought here after ambulance was stopped at another hospital (transferring hospital)and was told to bring Pt. #1 to receiving hospital. " At 7:21 AM, it indicated " General Reassessment: Pt#1 complaint or concerns: Ambulance experience ... Pt#1 stated there was a understanding between police department and transferring Hospital that Pt. #1 would go there ... ambulance was unloading Pt. #1, someone came out and told ambulance to take Pt. #1 to receiving Hospital. Pt. #1 told the ambulance Pt. #1 got hit by a car ... pt. #1'a girlfriend ran pt. #1 over, going about 20 to 25 miles per hour ... " Pt #1 was evaluated and underwent laboratory, electrocardiogram and Computerized Tomography testing and then was admitted voluntarily to the Psychiatric Unit. There was no documentation in medical record at receiving hospital to indicate Pt #1 received a Medical Screening Examination, was instructed on risks/ benefits of transfer, had transfer information sent, or that receiving hospital was contacted by transferring hospital to accept the transfer.

7. During an interview with the Emergency Services Director and the Nursing Director of the Emergency Department it was confirmed that Pt. #1 did not receive an MSE on 11/15/11 at 3:30 PM.

B. Based on a review of the Bylaws, Rules/Regulations, a review of the list of Emergency Department (ED) contracted physician providers (physicians and mid-levels), a review of the ED physician/mid-level schedule, ED medical record review, and staff interview, it was determined that in 4 of 4 (Pts #15, #16, #17, Pt #19) records reviewed the MSE was conducted by a nurse practitioner (NP), who is not qualified to perform an MSE per the Hospital's Medical Staff Bylaws. The Hospital failed to ensure that all MSE's were provided by an individual determined qualified by the Hospital's Bylaws, Rules/Regulations.

Findings include:

1. The Hospital's Bylaws, Rules/Regulations, effective June 13, 2011 were reviewed on 11/15/11. The Bylaws indicated under, "Part VI Emergency Services- " an individual who comes to the Hospital and requests an examination or treatment must receive an appropriate medical screening examination performed by a qualified medical person to determine whether... OB/L&D registered nurses are defined by the Medical Staff as qualified medical providers..." Section 5. "The Evaluation and Care of Patient in the Emergency Department. Revised June 22, 2010. A. The emergency physician/physician assistant shall examine and treat all persons who present themselves to the Emergency Department requesting evaluation and treatment..." There was no documentation in the Bylaws, Rules/Regulations that indicated a Nurse Practitioner (NP) was a qualified medical person authorized to provide the medical screening examination to individuals presenting to the Hospital's ED.

2. On 11/15/11 a request was made to the Nursing Director Emergency Department for a list of the contracted physician providers in the ED. A list of "Emergency Physicians" provided indicated that E #1 was identified as a NP.

3. The ED physician schedule for the months from April to the present were reviewed on 11/15/11. The schedule indicated E #1 worked 15 shifts in April, 18 shifts in May, 15 shifts in June, 14 shifts in July, 18 shifts in August, 14 shifts in September, 16 shifts in October, 7 shifts (scheduled to work 9 more shifts) in November.

4. During an interview with the medical Director of Emergency Services and the Medical Staff Manager, conducted on 11/15/11 at 3:05 PM, it was verbalized that E #1 was providing ED services since April 2011. The Director verbalized that E #1 was seeing ED patients but that a physician was co-signing her records.

5. During an interview with the Medical Director of Emergency Services and the Medical Staff Manager, conducted on 11/16/11 at 10:25 AM, it was verbalized that a Nurse Practitioner (E #1) began providing patient care in the Emergency Department. The Director of Emergency Services and the Medical Staff Manager stated that they were not aware E #1 was not designated in the Hospital ' s Bylaws, Rules/Regulations as a medical person qualified to perform medical screening examinations. The Medical Staff Manager verbalized that E #1 began providing care in the Emergency Department in April 2011. The medical Director of Emergency Services indicated E #1, who is a Nurse Practitioner, was providing MSE ' s in the ED.
6. The ED medical record of Pt #15 was reviewed on 11/16/11. It indicated Pt #15 (MDS) dated [DATE] with a chief complaint (CO) of Cough. Documentation in the physician's signature block indicated that the MSE for Pt #15 was completed by E #1, who is a Nurse Practitioner with only a co-signature by the ED physician and that E#1 discussed the case with the ED physician, but no physician MSE was completed. Pt #15 was discharged home.

7. The ED medical record of Pt #16 was reviewed on 11/16/11. It indicated Pt #16 (MDS) dated [DATE] with a CO of Right Hand Pain, Chronic Leg Pain, and Right Wrist Pain. Documentation indicated that the physician's signature block was signed by E #1. Documentation in the physician's signature block indicated that the MSE for Pt #16 was completed by E #1, who is a Nurse Practitioner with only a co-signature by the ED physician and that E#1 discussed the case with the ED physician, but no physician MSE was completed. Pt #16 was discharged home.

8. The ED medical record of Pt #17 was reviewed on 11/16/11. It indicated Pt #17 (MDS) dated [DATE] with a CO of Urinary Tract Infection/Dysfunctional Uterine and Bleeding. Documentation indicated that the physician's signature block was signed by E #1. Documentation in the physician's signature block indicated that the MSE for Pt #17 was completed by E #1, who is a Nurse Practitioner with only a co-signature by the ED physician and that E#1 discussed the case with the ED physician, but no physician MSE was completed. Pt #17 was discharged home.

9. The ED medical record of Pt. #19 was reviewed on 11/16/11. It indicated Pt. #19 (MDS) dated [DATE] with a chief complaint of Upper left quadrant abdominal pain. Pt. #19 had lab work , CT of abdomen and Intravenous fluids. Documentation indicated that the physician's signature block was signed by E #1. Documentation in the physician's signature block indicated that the MSE for Pt #19 was completed by E #1, who is a Nurse Practitioner with only a co-signature by the ED physician and that E#1 discussed the case with the ED physician, but no physician MSE was completed. Pt #19 was discharged home.

10. During an interview with the Medical Director of Emergency Services and the Medical Staff Manager, conducted on 11/16/11 at 10:25 AM, the above finding was confirmed.
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

A. Based on Policy and Procedure, a review of the required transfer form, EMS summary report, internal documentation medical record review from receiving hospital, and staff interview, it was determined that in 1 of 5 (Pt #1) medical records reviewed in which the patient was transferred, the Hospital failed to ensure Pt. #1 receiving medical treatment, documented the risks and benefits associated with the transfer,contacted a receiving hospital for an acceptable transfer from the Emergency Department (ED).

Findings include:

1. On 11/15/11 the Hospital policy titled "Emergency Services Patient Transfers to Another Facility" effective 1/18/10 was reviewed. It indicated "Statements: Prior to transfer to another facility the following must be accomplished: 1. The patient will have had a screening medical examination including, if necessary, any appropriate available ancillary test and/or medical specialty consultation. 2. All patients will be stabilized to the extent possible, prior to transfer. 3. The patient... will be advised of the reasons the transfer is recommended as well as the potential benefits of and/or risks of not being transferred..."

2. On 11/15/11 the Hospital form titled, "AUTHORIZATION FOR PATIENT TRANSFER" was presented. It was verbalized by the medical Director, Emergency Services and the Nursing Director, Emergency Department that this form is to be completed on all ED patients that are transferred to another facility. This form documented the EMTALA requirements for a proper transfer. This included a medical screening, stabilization, explanation of risks and benefits, contact and acceptance from the receiving facility, and mode of transfer.

3. The EMS summary report of Pt. #1, was reviewed on 11/15/11. It indicated on 10/23/11 "Dispatched to an emergency call for a [AGE] years old male patient suicidal. Upon arrival Pt. #1 found sitting on the curb at a gas station. Police Chief was on scene. PD (Police Department) said that pt #1 was suicidal and that Police Chief was calling around for a bed...The Police Chief told Emergency Medical Technicians (EMTs) that the hospital had a psych bed available. EMTs began to transport to the hospital ... hospital was contacted by cell phone when EMTs were 5 min away. Hospital ER (emergency room ) told EMTs that the hospital was not a psych facility. EMT told the hospital that PD called and that the hospital said the hospital had a room available and that the hospital was the closest Hospital. Hospital said to continue transport. When EMTs arrived at the hospital a nurse came out to meet EMTs. The nurse said that EMS were supposed to go to receiving hospital. EMT went into ER with nurse to confirm that EMS were supposed to go to receiving hospital. Another nurse told EMTs that EMS are supposed to go to receiving hospital and that the receiving hospital were expecting EMS. EMT was also told that receiving hospital had received the call from PD. EMT got back into the ambulance and told the pt. #1 that EMS are going to receiving hospital instead. Pt. #1 said okay and went back to resting..."

4. Internal Documentation from the ED Charge Nurse (E#2) dated 10/28/11, was reviewed on 11/15/11. It indicated that the E#2 received a phone call from the ED physician stating that there was a suicidal patient( Pt. #1) coming and E #2 stated the hospital was required to accept Pt #1 and that P. # 1 could not be diverted to a psych facility. E #2 was informed by the ED secretary (E#3) that the E#3 spoke with the receiving hospital and receiving hospital was expecting Pt. #1. The E #2 meet the EMTs in the ambulance bay and informed the EMTs that EMTs were at the wrong facility and the receiving hospital is expecting Pt. #1 and then EMS took Pt. #1 to receiving hospital

5. The medical record of Pt. #1 from receiving hospital was reviewed on 11/16/11. Pt #1 presented to receiving hospital ED per EMS on 10/23/11 at 5:22 AM with the Chief Complaint of " Suicidal Ideation. Nursing documentation indicated the following. Pt #1 had a history of Anxiety and Depression. Physician documentation further indicated a history of Bipolar Disorder. Nursing documentation indicated that Pt #1 broke up with girlfriend today and having problems with sister. Was just going to try and kill self. Girlfriend hit Pt. #1 with a car 10/22/11 at 8:00 PM. Having neck pain now ... " At 5:25 AM, nursing documentation indicated the Nursing Supervisor was notified " that pt. #1 was brought here after ambulance was stopped at another hospital (transferring hospital)and was told to bring Pt. #1 to receiving hospital. " At 7:21 AM, it indicated " General Reassessment: Pt#1 complaint or concerns: Ambulance experience ... Pt#1 stated there was a understanding between police department and transferring Hospital that Pt. #1 would go there ... ambulance was unloading Pt. #1, someone came out and told ambulance to take Pt. #1 to receiving Hospital. Pt. #1 told the ambulance Pt. #1 got hit by a car ... pt. #1'a girlfriend ran pt. #1 over, going about 20 to 25 miles per hour ... " Pt #1 was evaluated and underwent laboratory, electrocardiogram and Computerized Tomography testing and then was admitted voluntarily to the Psychiatric Unit. There was no documentation in medical record at receiving hospital to indicate Pt #1 received a Medical Screening Examination, was instructed on risks/ benefits of transfer, had transfer information sent, or that receiving hospital was contacted by transferring hospital to accept the transfer.

6. During an interview with the Medical Director, Emergency Services and the Nursing Director of Emergency Services, conducted on 11/15/11 at 3:05 PM, it was verbalized that the Medical Director of Emergency Services and the Nursing Director were aware of an EMTALA violation that occurred in October of 2011 related to Pt #1 being transported to their Hospital and not having a proper transfer to another facility. It was verbalized that the required form was not completed on Pt #1 prior to Pt. #1's transfer, nor was there any other documentation that indicated an appropriate transfer was conducted.

7. During an interview with the Medical Director, Emergency Services, conducted on 11/15/11 at 3:05 PM, the above findings for were confirmed.